Easter Seals Jobs

Employment Type:

Full time

Shift:

Description:

RHIT or LPN

Does not require RN

• Reviews assigned medical records in a timely manner for admission, concurrent or retrospective review using InterQual / MCG criteria to determine appropriate level of care.

• Follows the hospital Utilization Review Plan to ensure effective and efficient use of hospital services.

• Demonstrates competency with MCG and Interqual criteria.

• Analyzes and disseminates appropriate clinical information for payer authorization. Extracts pertinent information and communicates in a succinct fashion to the 3rd party payer. Demonstrates sound clinical judgement that supports IP level of care for appropriate reimbursement to the hospital.

• Demonstrates expertise in providing IS/SI criteria to Third Party Payers to obtain authorization for level of care and/or procedures for initial admission, concurrent or retrospective reimbursement.

• Contacts internal physician advisor on cases that do not meet established guidelines for admission or continued stay.

• In the event of an inpatient denial by the payer, obtains further documentation from the physician to support an IP level of care.

• Initiates and coordinates Peer to Peer discussions with physician and payer as warranted.

• Obtains authorizations as required for reimbursement from appropriate Third-Party Payor.

• Works with the Case Managers to obtain hospital to hospital transfer authorization as needed.

• Monitors the DNFB (discharged but not final billed) list to ensure timely claim filing.

• Communicates to the payer patient discharge date and discharge plan. Mediates between case manager and payer to ensure a seamless transition in care and appropriate post-acute follow-up.

• Provides updated Third-Party payor information to assigned Case Manager for continuity of care.

• Identifies areas of quality concerns, inappropriate use of resources and any other issues that restrict the implementation of hospital, department objectives and refers findings for appropriate follow-up.

• Reviews IP denials with the physician advisor to determine if a case should go to the Appeals Team.

• Assists other departments in the reimbursement process including, but not limited to, changes in inpatient, outpatient and observation status, identification of appropriate surgical status and other interventions needed to reduce patient and hospital liability of financial loss.

• Demonstrates proficiency in using various computer programs required including EPIC, Availity, Word, and Payor Portals.

• Responsible for combining admissions on those cases that are appropriate and communicating to Insurance Verification and Health Information Management.

• Functions as a resource to physician, hospital staff or departments and other ‘customers” of the hospital to assist in complying with the utilization review processes.

• Participates in UR Committee, department staff meetings and ad hoc committees on an as needed basis.

• Participates in review and analysis of outcome data related to UR functions and identification of system and process issues that contribute to denials.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran